Medical Chart Abstraction Form (approved 8/29/2019)

Form Approved

OMB No. 0920-1011

Exp. Date 01/31/2020

CDC Medical Record Abstraction Short Form for E-cigarette Investigation SHORT FORM

August 27, 2019

Page 1

Severe Pulmonary Disease Associated with E-cigarette Use Outbreak

MEDICAL CHART ABSTRACTION SHORT FORM (CDC)

August 27, 2019

Medical Chart Abstraction Short Form – Selected Variables

Demographics

Case number (de-identified):

Age:

Ethnicity

• Hispanic or Latino

• Not Hispanic or Latino

Race: (Select all that apply)

• White

• Black or African American

• Asian

• American Indian/Alaska Native

• Native Hawaiian or Other Pacific Islander

Sex

• Male

• Female

History of Present Illness

Admitted to hospital

• Yes

• No

Date of admission or initial evaluation (if not admitted):

Discharge diagnosis:

Date of initial symptom onset: ___________

Symptom at admission	Yes	No	Don’t Know or Not Documented
Shortness of breath
Difficulty breathing
Chest pain
Chest pain, pleuritic
Cough (any)
If yes (cough), productive?
Wheezing
Hemoptysis (coughing blood)
Nausea
Vomiting
Diarrhea
Abdominal pain
Unexpected weight loss over past 3 months (specify amount):_____________
Subjective (i.e. reported) fevers
Chills/Rigors
Headache
Stiff neck
Sore throat
Runny nose
Sneezing
Nasal congestion
Muscle Aches/myalgia
Joint pain
Sweats
Rash
Red or draining eyes

Other symptoms: ______________

*If not admitted, symptoms at most recent evaluation

Past medical history:

Check all that apply:

• Asthma

• Emphysema/bronchitis (COPD)

• Bronchiectasis

• Hypersensitivity pneumonitis

• Cystic Fibrosis

• Other chronic lung disease, specify: _____________

• Heart failure

• History of myocardial infarction (heart attack)

• Other cardiac diagnosis: __________

• HIV/AIDS

• Cancer, specify type ____________

• Injection Drug Use

• Other, specify type ___________

Vital Signs

Initial/first recorded temperature: _________ specify Fahrenheit/Celsius

Initial/first recorded heart rate:

Initial/first recorded respiratory rate:

Initial/first recorded systolic blood pressure:

Initial/first recorded diastolic blood pressure:

Initial/first recorded SpO2 on room air (pulse oximetry, %) :

Substance Use History

Tobacco Smoking Status (smoking of any combustible tobacco product, including cigarettes, cigars (regular cigars, little cigars, cigarillos), hookahs, roll-your-own cigarettes, pipes, and bidis)

• current smoker

• former smoker

• never smoker

• unknown

Vaping or e-cigarette use in past 90 days, includes using an electronic device (e.g., electronic nicotine delivery system (ENDS), electronic cigarette, e-cigarette, vaporizer, vape(s), vape pen, dab pen, or other) or dabbing to inhale substances (e.g., nicotine, marijuana, THC, THC concentrates, CBD, synthetic cannabinoids, flavorings, or other substances).

• current

• former

• never

• unknown

Substances vaped (check all that apply)

• Nicotine

• Marijuana, THC, THC concentrates, hash oil, wax

• Dank vapes

• Synthetic cannabinoids (e.g., K2 or Spice)

• CBD or CBD oil

• Flavors

• Other ___________

• Not documented

Combustible Marijuana Smoking status (does not include vaping or dabbing, see above; only include use of smoked marijuana (e.g., joint, pipe, bong; sometimes called cannabis, pot, weed, hashish, grass))

• current

• former

• never

• unknown

Combustible Synthetic Cannabinoids Smoking status (does not include vaping or dabbing, see above; only include use of synthetic cannabinoids (e.g. K2, Spice))

• current

• former

• never

• unknown

Other substances inhaled:

• Cocaine (crack)

• Methamphetamine

• Heroin

• Huffing (paint, glue, bath salts)

• Other_______________

Selected laboratory testing:

Admission sodium (Na):

Chloride (Cl):

Admission potassium (K):

Admission magnesium (Mg):

Admission blood urea nitrogen (BUN):

Admission creatinine:

Admission bicarbonate (CO2):

Admission Complete Blood Count:

White blood cells (WBC): ____________

WBC differential

% Neutrophils:

% Lymphocytes:

% Eosinophils:

% Monocytes:

% Basophils:

Hemoglobin:

Hematocrit:

Platelets:

Highest ALT (U/L):

Highest AST (U/L):

Admission total bilirubin:

Admission C-reactive protein (CRP):

Admission arterial blood gas (ABG) prior to mechanical ventilation:

pH: _____

pO₂: _____

pCO₂: _____

bicarbonate (HCO₃): ______

pulse oximetry O2 saturation (at the time of the ABG draw): ______

Special laboratory testing:

Indicate any positive laboratory tests for infectious, rheumatologic, hypersensitivity panel

(See long form medical abstraction form for detailed examples of these tests)

Test	Date of collection	Results

Imaging, medical procedures, and treatment:

Chest radiograph (x-ray) performed

□ Yes □ No □ Unknown

Initial chest radiograph (x-ray) findings:

Subsequent chest radiograph (x-ray) performed?

□ Yes □ No □ Unknown

Subsequent chest radiograph (x-ray) findings:

Chest CT (computed tomography) performed □ Yes □ No □ Unknown

Initial chest CT findings:

Bronchoscopy performed □ Yes □ No □ Unknown

Bronchoscopy findings:

Lung biopsy performed

□ Yes □ No □ Unknown

Lung biopsy findings:

Antimicrobials administered:

□ Yes □ No □ Unknown

Antimicrobials (e.g., antibiotics, antifungals, antivirals) administered. List all.

Antimicrobial name

Documented clinical response to antimicrobials:

□ Improvement

□ No change

□ Worsening clinical status

□ Unknown/not documented

Steroids administered:

□ Yes □ No □ Unknown

Steroid medication name	Route	Dose	Frequency

Documented clinical response to steroids:

□ Improvement

□ No change

□ Worsening clinical status

□ Unknown/not documented

Required the following care:

Intensive care unit (ICU) admission □ Yes □ No □ Unknown

Ventilatory support with CPAP or BiPAP □ Yes □ No □ Unknown

Mechanical ventilation via endotracheal or tracheal intubation □ Yes □ No □ Unknown

Diagnosis of Acute Respiratory Distress Syndrome (ARDS) □ Yes □ No □ Unknown

Placed on extracorporeal membrane oxygenation (ECMO) □ Yes □ No □ Unknown

Outcomes

Died? □ Yes □ No □ Unknown

Date of death (MM/DD/YYYY): _________

Cause of death: ____________

Autopsy performed? □ Yes □ No □ Unknown

Report available? □ Yes □ No □ Unknown

Autopsy findings: __________

Case status

• Confirmed

• Probable

• Not yet determined

• Not a case

Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)